Provider Demographics
NPI:1528254877
Name:NEPHROLOGY CONSULTANTS OF GRAND RAPIDS PC
Entity type:Organization
Organization Name:NEPHROLOGY CONSULTANTS OF GRAND RAPIDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER BILLING
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:TUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-866-2539
Mailing Address - Street 1:PO BOX 150185
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49515-0185
Mailing Address - Country:US
Mailing Address - Phone:616-866-2539
Mailing Address - Fax:616-866-3135
Practice Address - Street 1:4070 LAKE DR SE
Practice Address - Street 2:SUITE 201
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-774-8200
Practice Address - Fax:616-774-0304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIR0044045207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3371432Medicaid
MI3371432Medicaid
MI0M84580Medicare PIN